The nurse is evaluating the developmental skills of an eight-month-old child recently adopted from a foreign country. The nurse attempts to get the child to wave "bye-bye" and to play "patty-cake

Question

" When the child is unable to perform either skill, the nurse should: 1. Document developmental delay on the child's record.
2. Refer the child for an electroencephalogram.
3. Encourage the parents to seek medical attention for the child's developmental delay.
4. Recognize that this child's language skills and previous experience may not allow for these activities at this time.

Answer 1

4
Rationale 1: This quick assessment indicates only the child does not perform these skills, and a developmental delay cannot be based on this finding only.
Rationale 2: This is not a nursing intervention and would not determine developmental delay.
Rationale 3: Developmental delay is an assumption that cannot be confirmed at this time
Rationale 4: This is a reality for many children adopted from foreign countries. It is appropriate for the nurse to continue to monitor the child's development in future health care visits.
Global Rationale: